EXAM 1

gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluation patient care outcomes.

*includes both health history and physical assessment

a national model for health promotion and risk reduction developed by USDHHS

*goals: to increase the length and quality of life for Americans and to eliminate health disparities among different segments of the population

preventing problems

ex. immunizations, health teaching, safety precautions

early diagnosis of health problems and prompt treatment to prevent complications

ex. pap smears, vision and hearing testing, TB testing

focuses on preventing complications of an existing disease and promoting health to the highest  level

ex. diet teaching for patients with diabetes, inhaler teaching for patients with lung disease

• result oriented
• driven by patient, family, and community needs
• based on the nursing process, evidence-based thinking and scientific method
• requires specific knowledge
• is constantly reevaluating

1. gather assessmnt data- abnormal findings
2. draw inferences about what the issue is

• active listening
• restatement
• reflection-summary
• encouraging elaboration-assists the patients to more completely describe problems
• silence
• focusing
• clarification
• summarizing

1. false reassurance
2. sympathy
3. unwanted advice
4. biased questions
5. change of subject
6. distractions
7. technical language

emergency-nurses collect the most important info and defer obtaining details until patients are stable.

focused-question that relate to the current situation

comprehensive-takes place during an annual physical examination, for sports participation screening, and during a hospital admission

activities of daily living

ex. eating, dressing, and grooming

1. nursing admission assessment
2. history and physical examination by primary provider
3. primary provider's orders
4. POC (plan of care)
5. flow sheets document vital signs, intake and output and routine assessments
6. focused assessment sheets
7. MAR (medical administration record)
8. lab results
9. progress results
10. consultations
11. discharge or transfer summary

Health Insurance Portability and Accountability Act

*gives patients greater control over their medical records became effective in 2003.

*format focuses on a single problem:

Subjective-data

Objective-data

Analysis-of data to identify a problem

Plan- for treating or improving the problem

Interventions

Evaluation

Problem, Intervention, Evaluation

*incorporates the POC into the progress note

Data

Action

Response

*focus system of documentation organization

Outcome and Assessment Information Set

*accurately measures the patient's status at various specified points during an episode of care

*a shared mental model for improving communication between and among clinicians

Situation: state concisely why you are communicating

Background:  describe the circumstances leading up to the current situation

Assessment:  give objective and subjective data pertinent to the situation

Recommendation:  make suggestions for what needs to be done to manage the problem

pre- 120-139/ 80-90

stage 1- 140-159/ 90-99

stage 2- >160/ >100

1. transduction-stimuli cause impulse
2. transmission-periphery to spinal cord
3. perception-impulses transmitted to higher areas of the brain are identified as pain
4. modulation-inhibitory and facilitating input from the brain modulates or influences the sensory transmission at the level of the spinal cord

from dermis, epidermis, subcut; burning or sharp

subjective

*self-report, grimacing, rocking, guarding

stress,

BP, pulse, and respiration increase

muscle tension

one-dimensional: measures intensity

*Visual analog scale

*verbal descriptor scale

*numeric pain intensity scale

*combined thermometer scale

multidimensional pain scale-chronic pain, malignant pain or complex medical-surgical pain

*McGill pain questionnaire-experimentally induced circumstances

*brief pain inventory-cancer

*FACES

*FLACC

face

legs

activity

cry

consolability

*measure acute postoperative pain in children 2 months to 7yrs old

uses six faces ranging from happy to sad with tears

children 2 yrs and older can identify pain and point to its location

*between 7-10 yrs. children can begin using numeric rating scale

extreme anxiety

acute distress,

pallor

cyanosis

change in mental status

*interventions while continuing assessment

*obtain vitals: pulse, BP, oxygen sat.

stridor

respirations < 10 or >32

oxygen sat. < 92%

pulse < 55 or > 120

systolic BP <100 or > 170

new chest pain

temperature, pulse, respirations, and BP

*pain

**assess medications before vitals

35.9C-38C

96.7-100.5F

*most common and comfortable

.4-.5C

0.7-1F higher than oral

r-most accurate

t-quick, safe

carbohydrates

proteins

fats

vitamins

minerals

warer

major electrolytes

main source of energy

found in starch, fiber, grains, fruits, and vegetables

functions in cell structure and tissue maintenence

metabolism of most nutrients

D-needed for bone strength, and synthesis

B folate-metabolism and cell synthesis; leafy greens, seeks, OJ

B12-only water-soluble vitamin not found in plants; myelination, DNA synthesis

iron

zinc

calcium

potassium and sodium

Na+ regulates fluid balance, acid-base balance, muscular irritability

K+  " and skeletal muscle contractility

catholics: avoid meat on Fridays

Hinduism: avoid beef, pork, and alcohol

mormon:  avoid coffee, tea, alcohol, tobacco

seventh day adventist: lacto-ovo-vegetarians

Judaism: eat on Kosher meat no crustaceans; avoid consuming meat and milk together

Islam: avoid pork and birds of prey; fast during Ramadan

Buddhism:  lacto-ovo-vegetarian

18.5-24.9

BMI= weight/height2 x 703

suicide risk assessment

sex

age

depression

previous attempt

ethanol abuse

rational thought loss

social supports lacking

organize plan

no spouse

access to lethal means

sickness

Appearance

Behavior

Cognitive function

Thought process

MMSE-minimental status

biomedical

complementary and alternative medicine CAM

Roy's adaptation

Gordon's functional health

eudaimonistic model of health

individual

community

societal

violent crime committed by an offender who is related to the victim

ex. intimate partner violence (IPV), child maltreatment, sibling violence, elder abuse

1. epidermis-first line of defense; does not thin
2. dermis-supports epidermis, contains blood vessels, nerves, sebaceous glands which support nutritional needs of the epidermis
3. subcutaneous-provides insulation, storage of caloric reserves, and cushioning against external forces

1. eccrine-covers most of the body, open directly onto skin surface, and sweat in response to environmental or psychological stimuli

2.  apocrine- in the axillae and genital areas; open into hair follicles and become active during puberty, functioning decreases with age

**UVB-skin cancers

excess growth of scar tissue at the site of a healed skin injury

occur from acne, burns, chicken pox

1. inflammatory phase-begins within 30min of injury (2-3days)
2. proliferative phase-may last up to 4weeks
3. rmodeling phase-may last as long as 2 years

Right upper lung RUL

right lower lung RLL

Right middle lung RML

*right bronchii is more angled than the curved left bronchii

Left lower lung LLL

Left upper lung LUL

midsternal line

midclavicular line

ant., mid., post. axillary lines

vertebral line

scapular line

oblique fissure- between RLL and RML; b/t LUL and LLL (T3 spinous process)

horizontal fissure-b/t RUL and RML; not in the left lobes

base-bottom of lung fields; 6th rib MCL(midclavicular line)

apex-top of lungs; 2-4cm from the inner third of the clavicle

visceral pleura-lines the lungs

parietal pleura-lines the thoracic wall

pleural space- lubricates the two surfaces to reduce friction

declines

lungs lose elasticity, flexibility, and bone density

mucoid-bronchitis; clear, white or gray

purulent-bacterial infection; yellow or green

tenacious-dehydration; thick; heart failure; thin and frothy

hemoptysis-bloody sputum

inspection of patient-chest

palpation of chest

chest expansion

tactile fremitus-99

percussion of chest

diaphragmatic excursion

auscultation

auscultation of voice sounds

soft, low-pitched, and found over fine airways near the site of exchange;

whispering undertones

*inspiration > expiration

found over major bronchi that have fewer alveoli

*inspiration= expiration

loud, high-pitched, and found over the trachea and larynx

*inspiration < expiration

fine-high-pitched, soft crackling sounds (strand of hair)

coarse-low-pitched, moist, longer sounds (velcro)

low pitched snoring or gurgling sound that may clear with coughing

common with pneumonia

loud, coarse, and low-pitchedgrating or creaking sound (squeaky door)

pain that lasts beyond the normal healing period of 3-6 months; may be no cause

lower back pain or sickle cell pain

pain that results from damage to nerves in the peripheral or central nervous system

ex. diabetic peripheral neuropathy, postherapeutic neuralgia

lesions that have not been previously present

ex. macule, pustule, nodule, wheal, vesicle

lesion that has changed over time

ex keloid, lichen..., scars, fissure,

Asymmetry

Border irregularity

Color

Diameter larger than 6mm